Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.

MedStar author(s):
Citation: JAMA. 312(2):162-70, 2014 Jul.PMID: 25005653Institution: MedStar Heart & Vascular InstituteForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Aortic Valve Insufficiency/su [Surgery] | *Aortic Valve Stenosis/su [Surgery] | *Aortic Valve/su [Surgery] | *Bioprosthesis | *Heart Valve Prosthesis Implantation/mt [Methods] | Adult | Aged | Aged, 80 and over | Cardiac Catheterization | Female | Humans | Male | Middle Aged | Prosthesis Design | Prosthesis Failure | Registries | Survival Analysis | Treatment OutcomeYear: 2014Local holdings: Available online from MWHC library: 1998 - present, Available in print through MWHC library: 1999 - presentISSN:
  • 0098-7484
Name of journal: JAMA : the journal of the American Medical AssociationAbstract: CONCLUSIONS AND RELEVANCE: In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.DESIGN, SETTING, AND PARTICIPANTS: Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (<21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (>25 mm; 31%). Implanted devices included both balloon- and self-expandable valves.IMPORTANCE: Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed.MAIN OUTCOMES AND MEASURES: Survival, stroke, and New York Heart Association functional class.OBJECTIVE: To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves.RESULTS: Modes of bioprosthesis failure were stenosis (n=181 [39.4%]), regurgitation (n=139 [30.3%]), and combined (n=139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P=.005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P=.01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P=.001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (<21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P=.02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P=.008).All authors: Barbanti M, Bekeredjian R, Bleiziffer S, Brecker S, Cerillo AG, De Marco F, de Weger A, Dvir D, Ferrari E, Fiorina C, Hengstenberg C, Hildick-Smith D, Himbert D, Kodali S, Kornowski R, Laborde JC, Latib A, Lefevre T, Leon MB, Moat NE, Napodano M, Nissen H, Pasic M, Petronio AS, Piazza N, Presbitero P, Rodes-Cabau J, Schaefer U, Segev A, Tchetche D, Teles RC, Testa L, Treede H, Valve-in-Valve International Data Registry Investigators, Waksman R, Walther T, Webb JG, Wilbring M, Windecker SFiscal year: FY2015Digital Object Identifier: Date added to catalog: 2014-08-21
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Item type Current library Collection Call number Status Date due Barcode
Journal Article MedStar Authors Catalog Article 25005653 Available 25005653

Available online from MWHC library: 1998 - present, Available in print through MWHC library: 1999 - present

CONCLUSIONS AND RELEVANCE: In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.

DESIGN, SETTING, AND PARTICIPANTS: Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (<21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (>25 mm; 31%). Implanted devices included both balloon- and self-expandable valves.

IMPORTANCE: Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed.

MAIN OUTCOMES AND MEASURES: Survival, stroke, and New York Heart Association functional class.

OBJECTIVE: To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves.

RESULTS: Modes of bioprosthesis failure were stenosis (n=181 [39.4%]), regurgitation (n=139 [30.3%]), and combined (n=139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P=.005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P=.01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P=.001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (<21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P=.02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P=.008).

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